ERA15LA202

NTSB accident investigation · Beech D95 · Jacksonville, FL · April 23, 2015

Accident · No injuriesLimited investigationFinal report
Date
April 23, 2015, 16:16 local (20:16 UTC)
Place
Jacksonville, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N8950UBeech D95
Defining event
Landing-flare/touchdown: Landing gear not configured
Weather
Visual (VMC) · Day
Status
Completed · report February 17, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20150423005809A
Case key
91099

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to properly configure the airplane for landing. Contributing to the accident were pilot fatigue, distraction, and complacency and the failure of the landing gear warning horn to sound for reasons that could not be determined based on the available information.

Findings · 9

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech D95A: 2 casesAll aircraft: 1,391 casesProbable cause
Landing gear system: landing gear selectorAircraft › Aircraft systems · Not used/operatedBeech D95A: 1 caseAll aircraft: 54 casesProbable cause
Landing gear system: gear extension and retract sysAircraft › Aircraft systems · Not used/operatedBeech D95A: 2 casesAll aircraft: 416 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · PilotBeech D95A: 1 caseAll aircraft: 440 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedBeech D95A: 1 caseAll aircraft: 2,247 casesProbable cause
Attention/monitoringPersonnel issues › Psychological · PilotBeech D95A: 1 caseAll aircraft: 18 casesProbable cause
Personality/attitude: complacencyPersonnel issues › Psychological · PilotBeech D95A: 1 caseAll aircraft: 23 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot/owner reported that an air traffic controller vectored the airplane for the final approach for landing after the cross-country flight. The pilot noted that he performed the Before Landing checklist by rote and inadvertently positioned the flap handle believing that it was the landing gear handle. He added that he heard an electric motor actuate and that the airplane's speed and handling responded in a familiar fashion, so he continued the landing approach. The airplane subsequently landed with the landing gear retracted, which resulted in substantial damage to the airplane. The pilot reported that he did not confirm that the three green landing gear lights on the instrument panel had illuminated before landing but that the landing gear warning horn did not sound. The pilot also reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. After recovery, the airplane was placed on jacks, and the landing gear was extended and retracted with no anomalies noted. The airplane was then configured for landing, and the throttles were reduced to the idle-power position. Once configured, the landing gear warning horn did not sound as prescribed. Troubleshooting of the gear warning horn could not be performed; therefore, the cause of the horn malfunction could not be determined. The pilot reported that he experienced lengthy delays earlier in his trip, which lengthened his duty day and resulted in fatigue. The pilot stated that fatigue, distractions, and complacency could have been mitigated by a "strict adherence to the checklist and visual verification of gear status."

Factual narrative

On April 23, 2015, at 1616 eastern daylight time, a Beech D95A, N8950U, was substantially damaged while landing with the landing gear retracted at Jacksonville Executive Airport at Craig Field (CRG), Jacksonville, Florida. The private pilot/owner was not injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that departed Boone County Airport (HRO), Harrison, Arkansas. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. In a telephone conversation, the pilot said that air traffic control vectored the airplane for the final approach to Runway 14. He said he performed the before-landing or "GUMP" check by rote and inadvertently positioned the flap handle when he believed it was the landing gear handle. The pilot heard an electric motor actuate, and the airplane's speed and handling responded in familiar fashion, so he continued the landing approach to touchdown. He explained that he did not confirm three, illuminated, green, landing-gear lights on the instrument panel prior to landing. He subsequently reported to the air traffic controller, first responders, and to a Federal Aviation Administration (FAA) inspector that he had inadvertently lowered the flap handle instead of the gear handle, but that the gear warning horn did not sound. The pilot held a private pilot certificate with ratings for airplane single engine land, airplane multiengine land, and instrument airplane. His most recent FAA second class medical certificate was issued October 10, 2014. The pilot reported 864 total hours of flight experience, of which 199 hours were in the accident airplane make and model. The airplane was manufactured in 1965, and according to the pilot/owner, its most recent annual inspection was completed in February 2015, about 4,301 total aircraft hours. The airplane was recovered to a maintenance facility on CRG where it was placed on jacks. The landing gear was extended and retracted with no anomalies noted. The airplane was then configured for landing, and the throttles reduced to the idle-power position. Once configured, the gear warning horn did not sound as prescribed. Troubleshooting of the gear warning horn could not be performed, and therefore the cause of the horn malfunction was not determined. The pilot reported that there were no mechanical anomalies that would have precluded normal operation of the airplane. He further reported that he experienced lengthy delays earlier in his trip which lengthened his duty day resulting in fatigue. The pilot offered that fatigue, combined with other distractors as well as complacency, could have been mitigated by a "strict adherence to the checklist and visual verification of gear status."

Aircraft

Registration
N8950U
Reported as
Beech D95 (A)
Category
Airplane
Serial number
TD-641
Built
1965
Airframe hours
4,301
Engines
Lycoming IO-360-B1B, 180 horsepower, reciprocatingLycoming IO-360-B1B, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
B G E Enterprises LLC
Registered owner
B G E Enterprises LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 4, 2015 · 18 hours before
Departed
HRO · Harrison, AR
Destination
CRG · Jacksonville, FL
Flight plan
IFR
Airport
CRG · Jacksonville Executive At Crai, runway 14, 4,008 × 100 ft, asphalt
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 10, 2014
Seat
Left
Restraint
3-point
Flight hours
864 total · 199 in this make and model · 790 as pilot in command · 18 in the last 90 days · 10 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 57 °F
Altimeter
29.88 inHg
Observed at
CRG

Docket · 5

The files NTSB released with the investigation on January 11, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.